Women Presenting in Labor Should be Classified as ASA E

CON

Stephanie R. Goodman, MD
Assistant Professor of Anesthesiology
Department of Anesthesiology
College of Physicians & Surgeons of Columbia University

Women presenting for labor analgesia should NOT be classified using the ASA
"E" designation. The reasons for opposing this suggestion are based
on the historical and contemporary epidemiologic use of the ASA classification,
the rational medical definition of an emergency, and the implications for billing.

In 1940, a committee of the American Society of Anesthetists suggested the
concept of a physical status classification. This was originally designed for
the "collection and tabulation of statistical data in anesthesia"
and was specifically meant not to estimate operative risk.1The
system became known as the ASA Classification of Physical Status and attempted
to grade patients in relation to their physical state only. The relationship
to the operative procedure, the ability of the surgeon or anesthesiologist,
and the type of anesthesia were not part of the grading system.

The original classification contained 6 groups with the 5th and 6th groups
as emergencies of the first 4 classes. This was later modified in 1962 to include
the 5 groups, as we know them today.2 The original definition
of emergency in 1940 was "a surgical procedure which, in the surgeon's
opinion, should be performed without delay."1 In 1962, an "E"
was placed after the 5 groups in the event of an emergency operation, but the
definition of emergency was not refined.2

While labor analgesia is usually provided without delay, it is not a surgical
procedure; it is an anesthetic procedure. This original definition in 1940 was
not designed to apply to labor epidurals since at the time these were not performed.
Furthermore, if the "surgeon's opinion" determines the emergency designation,
then all cases could become emergencies so as not to "delay" the surgeon.
I have yet to meet a surgeon who doesn't try to manipulate the schedule for
his or her convenience.

Although the original creation of the Physical Status classification was not
meant to estimate operative risk, it has been used for over six decades and
been shown to correlate with surgical morbidity and mortality.3,4,5
Multiple studies have confirmed that when the ASA status contains an
"E," the risk of complications from surgery and anesthesia increases.6,7,8
Thus, the ASA classification has been of value in epidemiologic and statistical
studies of operative and anesthetic morbidity and mortality. There is no rationale
for using the "E" designation for labor epidurals since essentially
they would ALL be "E." In contrast, it is helpful to designate cesarean
sections as "E" versus "non-E" when done emergently or electively
since then outcome differences can be evaluated.

Currently, the ASA Physical Status classification system is used routinely
for billing purposes. Already by 1978, 43% of respondents to a postal questionnaire
were using it for billing.9 According to the 2002 American
Society of Anesthesiologists Relative Value Guide, anesthesia complicated by
emergency conditions can be coded as "E."10 Labor
epidurals or spinals are not "complicated" by the presence of labor,
they are necessitated (or at least requested) by its presence. An emergency
is "defined as existing when delay in treatment of the patient would lead
to a significant increase in the threat to life or body part."10
Although obstetric anesthesiologists frequently argue, with cause, that the
presence of an epidural in a high risk parturient may decrease morbidity, it
is exceptionally rare that a delay in the performance of labor analgesia would
lead to a significant increase in morbidity.

There are also financial consequences to the "E" designation. The
"E" status adds two units to the anesthesia bill, which can amount
to upwards of $200 an epidural, the exact amount of course depends on the specific
arrangements for anesthesiology reimbursement a department, group, or individual
has. Anesthesiologists who routinely use the "E" designation for billing
for labor analgesia could be viewed as billing fraudulently, given the Relative
Value Guide's definition of emergency. Depending on the reimbursement per unit,
this can quickly add up to a significant amount of potentially illegitimate
money, further adding unnecessarily to the costs of health care. In our department,
we place approximately 1400 epidurals for parturients each year who have private
insurance. At $80/unit this would provide us with an additional $224,000 each
year, if we billed this way. But we don't. Imagine how much money this amounts
to with over 4 million births in the United States each year. Although reimbursement
to anesthesiologists, especially from Medicare and Medicaid, is clearly inappropriately
low, it is equally inappropriate to "make it up" by overbilling for
labor analgesia.

Labor analgesia is a choice. As urgent as it feels and as quickly as it should
and needs to be provided, it is never an emergency. Just because it is not scheduled
does not mean it is an emergency. The laboring patient can decide at any moment,
even during the procedure, that she does or does not want an epidural. How can
that be an emergency? In no other medical circumstance would a patient decide
to have an emergency. Labor pain is the expected consequence of pregnancy. Usually
it is experienced as a continuum of increasingly severe pain. At the point when
a parturient chooses not to experience the pain, she may request to have an
epidural placed. Most anesthesiologists when faced with an emergency cesarean
section and an "emergency" labor epidural at the same time would deal
with the cesarean section first and delay the labor epidural. This is because
a labor epidural is not an emergency and should not be designated "E."